The Surgery of Ritual Circumcision

by Jacob Snowman

Stage VII. The dressing consists of a strip of sterilized and antiseptic lint or gauze long enough to encircle the penis below the glans two or three times, and wide enough to cover the whole space between the corona and the root of the penis, i.e. 4¼ in. × ¾ in. The first layer of dressing is applied entirely below the glans and covers over the whole of the reflected mucous membrane. Care must be taken to apply this strip of lint at the very root of the penis and to begin on the under surface; otherwise there is a tendency for the dressing in this latter position only to just to reach the edge of the incision and to push it back towards the scrotum and thus increase the size of the raw area.

The glans must be quite free of the dressing encircling the penis and must project completely beyond the strip of lint applied below it. This piece of lint or gauze adheres quite well by itself, but to ensure its remaining in position, it is better to secure it by surrounding it once or twice with a piece of sterilized tape and twisting up the ends. If this is done too tightly it may obstruct the free flow of urine, or congest the glans.

The dressing is completed by covering over the naked and projecting glans with a square piece of antiseptic gauze. A diaper folded in the ordinary triangular shape is then put on, and this is secured firmly by means of broad tape. Two or three turns must be given round the thighs so as to keep them fixed, and the ends are to be tied over the hip.

During the after treatment the re-dressing may be regulated as follows. After about 10 or 12 hours, but at any rate within the first 24 hours, the piece of gauze covering the glans must be removed and the tape surrounding the dressing untwisted and also removed. If the circumcision has been properly and carefully performed, so that the whole of the mucous membrane and skin are kept back by the dressing, and the whole of the glans remains exposed, nothing further need be done but to replace some fresh gauze over the glans. On the following day the whole of the dressing should be removed, and gauze be re-applied around the penis leaving the end of the glans free. This dressing will fall off when the infant is in the bath, and may be renovated as often as necessary. As an alternative procedure the whole dressing may be removed after the first 24 hours, and the part re-dressed with gauze.

[1] The performance of Metzizah according to statutory Jewish Law consists of suction by the mouth. The original sources of this practice indicate that it was considered an essential part of the operation in the same way as the dressing of the wound was. Failure to carry out this measure was regarded as constituting a serious risk to the infant. The possible dangers of this practice have become obvious during recent years and direct suction of the wound is, from every point of view, inadmissible. In order to carry out the ancient practice a device is used by some Mohelim by which the suction is performed through a small glass tube with a perforation at its end and containing a piece of absorbent wool in its interior.

Circumcision in Abnormal Cases.

The penis is subject to many departures from its usual anatomy, but here it will only be necessary to notice some of the more usual abnormalities.

1st. In some cases the penis is sunken into the pubic skin, so that on grasping the prepuce the whole integument of the penis is pulled up leaving the organ itself buried in the skin behind. It will be found that in many of these cases the testicles have not descended into the scrotum. The first stage of the operation, in these instances, is all important. The root of the penis is embraced between the second and third fingers of the right hand as previously explained and firm pressure backwards is made until a definite erection is made. The amount of skin to be amputated must be very accurately estimated, the shield carefully adjusted in an oblique direction, as in these cases the inclusion of some of the skin of the scrotum is very easy. The mucous membrane often proves to be very thick, but whatever its consistence may be it should be cut away with scissors after reflection as this proceeding helps to prevent the glans sinking back into the skin. A careful examination of the infant must be made in these cases because they frequently denote immature development, and call for postponement of the performance of the circumcision.

2nd. The prepuce is sometimes deficient. The upper portion of the glans may be exposed and project beyond the short prepuce. The amount of the latter which should be removed is so small, that on pulling it forward there is not sufficient in the small circle of skin for the fingers to obtain a firm grasp. In this case forceps should be employed to hold the foreskin.